Gluten free foods Policy Statement: This policy defines the decision made by NHS Wirral regarding the prescribing of gluten free food

Transcription

1 Prescribing Policy Gluten free foods Policy Statement: This policy defines the decision made by NHS Wirral regarding the prescribing of gluten free food NHS Wirral has agreed that the prescribing of gluten-free food for patients with a clinical diagnosis of coeliac disease or other gluten enteropathy will be limited to:- Bread loaves, bread mix, flour, flour mix, crackers and pasta only, and Specified cost-effective brands of these food groups, and to Prescribing the specified quantities. Fresh bread may be prescribed, providing the pharmacy orders it from a wholesaler that does not apply handling charges. Pizza bases may be prescribed for children only, where the GP considers this a necessary solution. What this means for patients is:- Your GP should not prescribe outside the policy criteria on NHS prescription because this does not represent optimal use of limited NHS resources. If you wish to use a product other than one your GP is able to prescribe you will need to purchase your own supply. You can contact haveyoursay@wirral.nhs.uk if you have any concerns Version 1.4 Approved by: Wirral CCG Operational Group Date Approved: Date of implementation: Produced by: Medicines Management Team Review Date: Earliest of either SHA guidance, NICE publication or five years from issue.

2

3 Further information about this document: Document name Prescribing Policy: Gluten free products Category of Document in The Policy Schedule Author(s) Contact(s) for further information about this document This document should be read in conjunction with Published by If you have any concerns please contact us on Copies of this document are available from Commissioning Policy Medicines Management Team Telephone: Wirral Medicines Guide Gluten-free prescribing guidelines NHS Wirral Old Market House Hamilton Street Birkenhead Wirral CH41 5AL Telephone: Freephone: Website: Hard copies from the Medicines Management Team Version Control: Version History: Version Number Reviewing Committee / Officer Date 1.0 Primary Care Prescribing Committee Professional Executive Committee Professional Executive Committee Professional Executive Committee Wirral CCG Operational Group The following terms are used in this document Coeliac UK British National Formulary (BNF) Coeliac UK is the leading charity working for people with coeliac disease and dermatitis herpetiformis (DH). The BNF provides prescribers, pharmacists and other health care professionals e.g. nurses with up to date information about medicines prescribed in the UK

4

5 Prescribing Policy Gluten Free Foods 1. BACKGROUND 1.1 The purpose of this policy is to outline the decision taken by NHS Wirral regarding the prescribing of gluten free products. This policy applies to all prescribers, both medical and non-medical. 1.2 Patients suffering from coeliac and other diseases related to gluten intolerance need to adhere to a lifelong gluten free diet. Many foods are naturally free of gluten, which mainly exists in cereal products such as those made from wheat. 1.3 Gluten free foods are defined as Borderline Substances in the Drug Tariff and may be prescribed to patients with established gluten enteropathy. Coeliac UK, a charity supported by the Primary Care Society for Gastroenterology and the British Dietetic Association, has produced guidelines outlining the quantities of specialised foods required by coeliac patients depending on their age and levels of physical activity. The quantities recommended in the Wirral Guidelines are the same as those in the guidelines produced by Coeliac UK. 1.4 The quantities recommended in the guidelines are higher than those needed by many patients. Additional dietary requirements should be achieved by choosing healthy foods which are naturally gluten free. 1.5 The price the NHS pays for gluten-free food is significantly higher than that charged by supermarkets. A wide variety of gluten free food can be purchased at all supermarkets. 1.6 Fresh bread loaves may be prescribed, providing the pharmacy orders them via the Alliance wholesaler. Since 1 st November, fresh bread has been available to pharmacies via the Alliance wholesaler without incurring handling and delivery charges (these range from per delivery for products ordered directly from the manufacturer). Additionally, bread mix is available on prescription to bake fresh bread. 1.7 Some brands are considerably more expensive than others. Prices are in Appendix 6.1 in the BNF. 2. EVIDENCE 2.1 Coeliac UK based their recommendations on the National Diet and Nutrition Surveys and the Eatwell Plate produced by the Food Standards Agency. 2.2 The guidelines are based on the Eatwell plate model and for gluten-free prescribable foods to provide 15% total energy (total carbohydrate should provide 50% total energy which includes naturally gluten-free foods such as

6 rice, potatoes and suitable rice or corn based breakfast cereals, intrinsic and milk sugars as well as gluten-free prescribable foods). 2.3 NICE published a clinical guideline on Coeliac Disease in May This does not provide any dietary advice. 2.4 The Department of Health produced an information sheet called Gluten-free foods local options in This provides guidance around the supply of gluten-free food to patients. Under the heading of How Much Food, it recommends PCTs reach agreement with local GPs on the supply of gluten fee food at NHS expense. 2.5 NHS Wirral prescribing expenditure is close to the NW Strategic Health Authority average and this prescribing policy is followed closely. 3. CONCLUSIONS 3.1 Adhering to a gluten free diet improves symptom control and quality of life in patients with coeliac disease and protects against complications. 3.2 The recommendations made by Coeliac UK refer to minimum quantities. However, if patients supplement their diet with naturally gluten free alternatives such as potatoes and rice, they may not need these quantities. 3.3 Basic staple items ie bread loaves, pasta, crackers, bread mix, flour mix and flour may be prescribed in appropriate quantities. Patients should purchase other food items at supermarkets. 3.4 Biscuits, pizza bases, cake mix, ready meals and other items should not be prescribed. However an exception may be made where the GP considers it a necessary solution: pizza bases may be prescribed for some children eg low income families struggling with gluten free diets. These patients should be warned they would need to purchase pizza bases once they become adult. 3.5 Patients who are overweight should reduce their total intake including carbohydrate intake in order to achieve weight loss. 3.6 Gluten free products should not be prescribed unless there is a clinical diagnosis of coeliac disease, dermatitis herpatiformis or steatorrhoea due to gluten sensitivity. 4. RESPONSIBILITY FOR IMPLEMENTATION 4.1 Responsibility for implementation lies with Wirral CCG.

7 5. ROUTE FOR POLICY DEVELOPMENT AND RATIFICATION 5.1 Draft policies are subject to consultation at local clinical meetings with Medical Directors, GPs and pharmacists. The final policies are ratified at the Wirral CCG Operational Group and published on the PCT website. 5.2 Local dieticians have been consulted during the development of this policy. 6. REFERENCES 6.1 The National Diet & Nutrition Survey: Adults aged 19 to 64 years. Types and quantities of foods consumed. A survey carried out in Great Britain on behalf of the Food Standards Agency and the Department of Health by the Social Survey Division of the Office for National Statistics and Medical Research Council Human Nutrition Research West Cheshire Prescribing Policy: Gluten free foods Coeliac UK The Department of Health ments/digitalasset/dh_ pdf 6.5 The Eatwell plate.

8 Appendix 1: Local prescribing guideline Gluten-Free Foods Prescribing Guideline NHS Wirral Commissioning Policy December 2012 Only bread loaves, pasta, crackers, bread mix, flour mix and flour should be supplied on prescription. Pharmacies must order fresh bread via the Alliance wholesaler. Other food items can be purchased in supermarkets. Prescribing of the basic food groups is limited to the cost-effective brands. Recommended quantities should not be exceeded. The diet should be supplemented with carbohydrates that are naturally gluten free. Unit Values for Basic Prescribable Foods 400g bread loaves 500g flour, bread mix or flour mix 200g crackers 250g pasta 1 unit 2 units 1 unit 1 unit Monthly Units for Men Aged years 18 Aged Aged Units for Women Aged years 14 Aged Breastfeeding 18 Pregnancy 3 rd trim. 15 Units for Children Aged 1-3 years 10 Aged 4-6 years 11 Aged 7-10 years 13 Aged years 15 Aged years 18 Notes Quantities are suggested only and may be decreased where appropriate. Refer to the dietician service if necessary. For high physical activity levels eg manual workers add 4 units Review date Some children may be prescribed pizza bases if the GP considers this a necessary solution Each prescription should be for one month s supply of food Information obtained from Coeliac UK. For more information, visit Cost Effective Brands Examples include Dietary Specials and Glutafin Juvela products are expensive apart from bread Juvela mix may be prescribed if cheaper bands have been tried unsuccessfully See MIMS or Appendix 6.1 in the BNF for current prices Scriptswitch will be updated with current cost effective options Version 3. Guideline updated by: Helen Dingle, Prescribing Adviser, NHS Wirral Approved by:medicines Clinical Guidance Subcommittee of Wirral Drug and Therapeutics Committee 1 February 2013 Review date: 2016

9 Appendix 2 Useful questions to ask a patient: a) Does this person understand their condition and the importance of compliance? b) Have they tasted any samples of gluten-free foods? c) How old is the patient? (an elderly patient may require smaller quantities than a younger adult for example) d) How active is the patient? (for similar reasons as above) e) What was the person s consumption of similar foods (i.e. bread, flour, pasta ) prior to diagnosis? If particularly high the person may struggle without similar foods on prescription f) What else is the patient eating to ensure a balanced diet? This is a particularly important question, as research suggests that these foods make up at maximum approximately 30% of a coeliac patient s diet. If the rest of their diet is relatively low in fat, high in fruit and vegetables and contains suitable protein sources, it should be fine to proceed with their prescription preferences. It can be quite difficult to estimate appropriate quantities of gluten free foods to prescribe. A useful starting point is to ask the patient to estimate the quantities of these types foods that they would normally consume per month (i.e. before they started experiencing symptoms/were diagnosed). Having agreed on a list of gluten-free foods for prescription, it is important to provide the patient with flexibility to change items. A person s needs or preferences for food often changes over time. If you are unable to ascertain whether the person is following a balanced diet, it may be worth referring them to a Dietician for assessment.